OAE Hearing Screening and Follow-up Training Workshop Agenda

OAE Hearing Screening and Follow-up Training Workshop Agenda 8:00 8:15 Sign-in, breakfast snack and get settled 8:15 8:45 Activity 1: Get Started 8:45 9:30 Activity 2: Introduce OAE Hearing Screening 9:30 9:45 Break 9:45 10:15 Activity 3: Practice Hearing Screening 10:15 10:30 Activity 4: Introduce OAE Hearing Screening Protocol and Documentation Forms 10:30 12:00 Activity 5: Conduct Hearing Screenings with Children 12:00 12:45 Lunch 12:45 1:15 Activity 6: Review Equipment Care and Maintenance and Helpful Hints for Screening 1:15 1:45 Activity 7: Establish a Hearing Screening Data Collection and Tracking Process 1:45 2:00 Activity 8: Conclude the Training 1

Pre-Workshop Preparation 1. ECHO Team members set up at workshop location 7:15 8:00 See the Workshop Resources section, for a checklist of set-up activities. 2. Participants Arrive 8:00 8:15 Sign-in Breakfast snack Get settled 2

Activity 1 8:15 8:45 Get Started 1. Provide participants with a brief overview the rationale for periodic, objective hearing screening for children 0-3 years of age. The points below can be summarized as a preliminary orientation to participation in the project: Incidence and implications of hearing loss Hearing loss is the most common birth defect in the U.S. and it can also occur at any subsequent time in a child s life. In addition, childhood ear infections can also result in temporary hearing loss Unidentified and untreated, hearing loss negatively affects a child s language development, educational achievement, and literacy levels. Advances in early hearing detection and intervention Recent technological advances have made it practical to conduct physiological hearing screening of infants and young children; most babies in the U.S. are now being screened at birth in hospital-based newborn hearing screening programs. A screening procedure called Otoacoustic Emissions (OAE) is now commonly used to screen babies only a few hours old. This same technology can also help identify young children who have permanent or temporary hearing losses. Early Hearing Detection and Intervention (EHDI) programs have been established in each state to assist hospitals in their hearing screening efforts and to see that children identified through screening receive timely and appropriate audiological assessment and services. Implications for continuous screening in Head Start programs Head Start has a long-standing requirement that all children served receive a hearing screening within 45 days of entry into the program. The technological advances and experiences from hospital-based newborn screening efforts can be expanded into early childhood settings to update screening practices. Periodic screening throughout childhood is critical to assess hearing health. Otoacoustic emissions (OAE) is an appropriate physiologic screening tool to use with infants, toddlers, and young children because it is reliable, easy for non-audiologists to use, painless, and does not require a behavioral response from the child. Overview of the feasibility pilot project From 2001-2008, the Administration for Children and Families, Office of Head Start funded a series of projects to assess the feasibility of helping Head Start grantees to use 3

OAE screening equipment. These projects have been carried out by the National Center for Hearing Assessment and Management (NCHAM). Impressive outcomes were found in terms of the feasibility of updating screening practices and in the numbers of children identified with a wide range of hearing disorders. The training materials that will be used today, along with the OAE hearing screening and follow-up protocol and accompanying forms, were developed and tested by NCHAM with more than 100 Head Start grantees across 14 states. The screening protocol was designed specifically to reflect recommendations and guidelines from the American Speech-Language-Hearing Association Audiological Assessment Panel and the American Academy of Pediatrics AND to be practical for Head Start grantees to implement. The success of the original projects funded by the Office of Head Start has led to the dissemination of these training materials to all Head Start programs serving children 0-3 years of age. 2. Introduce the Trainer(s). Provide a brief description of each member s area of expertise, the role they play on the training team and the role they will play during the training. Briefly introduce the EHDI system, its role and its potential relationship to the Head Start s hearing screening activities.. 3. Elicit introductions of each participant. Ask each participant to offer their name, their title, and the role they play in the program. 4. Elicit information about current screening practices. Although this information will have been gathered in preparation for the training, take a moment to ask the participants the following questions: a) What hearing screening methods are you currently using and how have you felt about it up until now? b) Who will actually be doing the hearing screening and who is participating in the training as an administrator who will not actually be doing hand on screening of children? c) What is your familiarity with OAE screening? Build participant confidence that they are like the other diverse participants who have already experienced success in updating their screening practices through the use of OAE technology. Remind participants that this is an informal training process, that the smallgroup nature of the workshop is intended to make sure that each person leaves with the confidence they need to get started doing OAE screenings. 4

5. Overview the day. Take a minute to provide an overview of the: Objectives of the day: To provide all participant with basic information about the OAE hearing screening process, hands-on experience using the equipment to screen young children, and an appropriate screening protocol to follow for children birth to 3 years of age. Agenda. See appendix and http://infanthearing.org/earlychildhood/resources.html. Materials and Equipment. Acquaint participants with the Instructional Guide and screening forms that will be used. Explain that all information that will be covered during the workshop is included in these materials. Participants will be asked to share equipment, approximately 3-4 individuals per unit. Take a moment now to form equipment-sharing groups. Facility and host site policies. Acquaint the participants with where restrooms are, vending machines, and make any other logistical announcements related to compliance with host site policies, etc. 5

Activity 2 8:45 9:30 Introduce OAE Hearing Screening 1. Prepare participants to watch Part 1 of the training video using the following prompt: Today you ll see a lot of information presented on a video. Don t worry about remembering it all. The same information is included in your copy of the Instructional Guide. In addition, this same video is included on a CD in your Guide so you ll be able to review all the concepts as you need to. This first segment of the video explains: Why we are screening How we will be screening Overview of the auditory system and OAE Screening The OAE Screening process The screener s role The most important things for you to focus on will be: How the OAE screening procedure can help to identify children who need further hearing assessment, and Your role as a screener in that process. 2. Show Part 1 of the training video, Getting a Hearing Head Start: Updating Early Childhood Hearing Screening Practices. (Note that the information in the video appears in the Instructional Guide.) Pause at the end of Part 1 when prompted. 3. Review important concepts. Spend a minute or two reviewing important concepts and answering any questions participants may have about this segment. Avoid getting into very detailed explanations about the auditory system remember that participants are learning to be screeners and therefore need to understand only general concepts of how the hearing system and OAE screening work. Help participants focus on basic concepts, using the prompts provided below to elicit their responses: 6

Let s review a few key points from the video: The three main parts of the ear that normally transmit sound to the brain are..? (The outer ear... the middle ear...and the...inner ear or cochlea. ) In a healthy ear, where the inner ear is functioning normally, the cochlea sends the sound signal to the brain and it simultaneously...? (emits an echo that can be measured by sensitive equipment.) If there is excessive wax or debris in the child s ear canal, blocking the sound going in to the cochlea or the emission coming back out, the screening result will be...? ( Refer because no measurable OAE is present.) If the middle ear is filled with fluid--often associated with middle ear infection-- the screening result will be...? ( Refer because no measurable OAE is present.) If the cochlea isn t functioning properly, the screening result will be... ( Refer because no measurable OAE is present.) 4. Prepare participants to watch the Part 2 of the training video using the following prompts: During Part 2 of the video, you are going to see a variety of types of hearing screening equipment demonstrated. The important concepts to learn are that: Even though there are various types of portable OAE screening equipment on the market, they share common elements. No matter which type of equipment you will be using, the screening process is very similar. Screening can be broken down into a simple step-by step process. Do not worry about assembling your equipment until we turn the video off. At that time, we will go through the entire process of operating your equipment as we practice using it on each other. Divide participants into screening teams of up to 4 individuals in preparation for later practice and invite them to open their carrying cases so they can view the equipment. Designate one member of the ECHO Team to be the coach for each team. 5. Show Part 2 of the training video, Getting a Hearing Head Start: Updating Early Childhood Hearing Screening Practices. (Note that the information in the video appears in the Instructional Guide.) Pause at the end of Part 2 when prompted. 7

6. Demonstrate OAE Screening Using a member of the ECHO Team who typically passes on OAE screening (if possible); ask the person to sit in the demonstration chair. Verbally walk participants through the various screening steps as you demonstrate each one: a) Prepare the environment--have a place for the child to sit, a place to put the equipment and supplies, toys, and a place to write the results. Emphasize the importance of preparing this in advance, noting that the time children will wait for you to get organized is minimal. b) Visual inspection of the ear and ear canal--note what you are looking for. c) Select probe tip or cover --select the largest tip for the ear as that is likely to create a better seal--this will NOT increase discomfort for the child--note that selecting probe tips is something that screeners will learn to do over time. Even experienced audiologists sometimes have to try a couple of different tips before they get the right one for a given child. d) Place the probe tip firmly on the probe--if using a foam tip, demonstrate that the tip should be compressed to form a mushroom shape before insertion in the ear canal. e) Insert the probe in the ear canal--emphasizing the importance of a snug fit that enables you to remove your hand from the probe once it is in the ear and that the goal is to seal the ear with the probe tip. f) Start the screening process by pushing the appropriate buttons. g) Describe the result and, if possible, show participants the display screen. Repeat the demonstration on the other ear. Point out that: You can use the same probe tip on both ears of a single individual but you should NEVER use the same probe tips ACROSS more than one individual for disease control purposes. Break 9:30 9:45 8

Activity 3 9:45 10:15 Practice Hearing Screening During this section of the training, participants will have their first opportunity to learn to use the screening equipment by screening each other s ears. Complete this activity by doing the following: 1. Overview the screening process, which includes four primary elements: a) Preparing the screening environment. b) Assembling/preparing the equipment and materials. c) Performing the screening (including visual inspection and the OAE screening). d) Documenting screening results (will be covered in Activity 4).. 2. Engage training assistants (if you have them) in assisting the participants. 3. Instruct the participants to: a) Identify one person who will be screened and one who will do the screening. b) Prepare the screening environment. c) Prepare equipment and materials, including turning on the screening equipment. d) Complete visual inspection. e) Select probe tip, pressing it firmly over the end of the probe. f) Attach cord to clothing. g) Insert probe tip firmly in the ear canal. h) Start the test. i) Observe the screening equipment to note how the test is progressing. Repeat on other ear. Then switch roles and have the person who was screened perform the screening. Complete this process until all members have performed several screenings and have also had a chance to experience having their own ears screened. You will probably want to reassure participants in advance that the OAE screening tool is optimal for screening children, but is not optimal for screening adults so they should not be alarmed if their ears do not pass. 4. Debrief Elicit comments and questions from each practice team and their coach. The following are commonly asked questions during the first practice experience and potential responses: Why might some adults refer during an OAE screening? While OAE technology is the best tool available for screening the hearing of children 0-3 years of age, it is not the optimal screening procedure for adults. It's not uncommon for adults to refer on an OAE screening for a variety of reasons--most of which would not warrant follow-up diagnostic evaluation. 9

What do the various error messages on the screen mean? The error messages are usually telling you something about the probe fit and/or the amount of noise that is interfering with the screening process, but the messages are not always completely specific or accurate. Therefore, when you get an error message, the important thing is to try again, making sure you are using the largest probe tip possible, that the probe is clear of wax or other debris and connected firmly with the screening unit, and that you have the probe inserted snugly so that it remains securely in the ear canal after you release it. Why can t you hold the probe in the ear? Attempting to hold the probe is not a successful screening strategy because it can easily cause the probe tip to press against the ear canal wall, thus interfering with the screening How do you know what size of probe tip/cover to select? It is impossible to select the right probe tip 100% of the time. Occasionally even very experienced audiologists will try multiple tips on a given child in order to get the optimal fit. Selecting the right size probe tip is something you will learn with experience. Won t selecting a probe tip/cover that is too large hurt the child? No, in fact, the opposite is true. The inner portion of the ear canal is the part that is the most sensitive, so if a probe tip is too small, and the probe is therefore inserted too deeply, that is more likely to cause discomfort than using a larger tip would. Won t you hurt the person being screened if you pull on the fleshy outer portion of the ear as you examine the ear and place the probe tip? Most people are more timid than they need to be at first. Pulling back or stretching the fleshy portion of the ear typically does not cause pain in a healthy ear and it helps to open up the ear canal to accept the probe. And, when you examine an ear confidently, the child will be less likely resist the process. If you get a refer or fail result, what should you do? Try again! Assuming the child continues to cooperate, it is always a good idea to examine the probe tip for debris (changing to a different probe tip size if the fit seems too loose), reinsert it, and try screening again immediately, since a refer can result from poor probe fit, extraneous noise, or excessive child movement. Always double check your refer or fail results by obtaining them one or two additional times during the screening session if possible. If you get a pass result, is there a chance that this is not valid? A pass is the most reliable result you will get from an OAE screen. Once you receive a pass, you do not need to rescreen. 10

Activity 4 10:15 10:30 Introduce OAE Hearing Screening Protocol and Documentation Forms 1. Prepare participants to watch Part 3 of the training video using the following prompt: In this next segment of the video you ll be introduced to the hearing screening protocol. Don t worry about trying to remember every detail of the protocol--the forms you will be using to document screening outcomes will lead you through that process for each child. The important things to pay attention to in this segment are that: You need to conduct more than one screening session with some children who do not pass during the first OAE screening attempt. You need to screen or rescreen children who have been treated/cleared by their health care provider. There are simple things you can do to increase your effectiveness as a screener and minimize the number of children who need to be rescreened or referred. 2. Show Part 3 of the training video, Getting a Hearing Head Start: Updating Early Childhood Hearing Screening Practices. (Note that the information in the video appears in the Instructional Guide.) Pause at the end of Part 3 when prompted. 3. Walk participants through filling out an OAE Hearing Screening Form documenting the results of their own recent hearing screening. You may want to have participants turn to pages 19-23 in their Instructional Guide as you discuss each item on the Screening Form. a) Head Start Center ID This is used if you are collecting data across program sites. b) Child s Name Fill in the name of the individual screened. c) Initial Screen or a Rescreen Check one of two boxes: For an Initial screen, fill out additional demographics related to the date of birth, ethnicity, and gender as well as whether the child was known to have been screened at birth and, if so, the results. d) Screener Name and Title-- Fill in the name and title of the person conducting the screening. e) Location of screening Check the box to indicate whether screening is conducted in a home, Head Start Center, or other location. f) Screening Results/Left Ear and Right Ear Visual Inspection: If Refer, note screening date and make appointment with Primary Care Provider; if Pass, continue with OAE screening. 11

1 st OAE: If Can t Test or Refer, screen again within a 2 week period; if Pass, screening is complete, no further action needed. 2 nd OAE: If Can t Test or Refer, refer to a health care provider; if Pass, screening is complete, no further action needed. (Note: Using discretion, programs may refer child to the Primary Care Provider after the 1 st screening. For example, if parents have concerns about the child s ability to hear; if the family will be moving in the near future; if the Head Start program will be closing shortly; and/or if it will not be possible to complete the screening in a timely way, programs may choose to refer the child before completing two screening sessions. g) Children Referred for Medical Follow-up MUST be rescreened after clearance from their Primary Care Provider. If the child was treated for ear infection, it is best to wait 4 6 weeks until excess fluid in the middle ear has had time to dissipate. If the child does not pass screening after medical clearance, make an appointment with a Pediatric Audiologist. h) Approximate total time required for screening Estimate the number of minutes required to complete the visual inspection, the OAE screening for each ear, and to document screening results. 3. Discuss the Diagnostic Follow-up Form. A Diagnostic Follow-up Form will need to be completed on a smaller number of children (probably no more than 10%) who are referred from screening for medical or audiological care. (Note that instructions for the Follow-up Form can be found in the Instructional Guide.) When a child refers from screening, it is a good time for the Head Start program to ensure that the child has a Medical Home with a health care provider who can oversee the child s ongoing care. To obtain this follow-up information, the Head Start program may choose to: Send a blank copy of the Follow-up Form with the child to the referral appointment and request that the provider fill it out and return it to the program, or Call the provider after the appointment to find out the results and document them on the Form. In any case, it is very important that both the Head Start program obtain and document the results of every referral and what next steps for a child the primary care provider or audiologist recommends. Reinforce to participants that as their consulting Audiologist you will be glad to assist them in understanding/interpreting referral results and what needs to happen next to provide the child with timely and appropriate care. 4. Review important concepts. Spend a minute or two reviewing important concepts and answering any questions participants may have about the protocol. Help participants focus on basic concepts, using the prompts provided below: Let s review a few key points from the video: If a child does not pass the OAE screening during a screening session, what needs to happen next? (Referral to a health care provider.) 12

If a child is referred to a health care provider, why do you need to rescreen after treatment/medical clearance? (Most health care providers do not have the proper equipment to assess cochlear function.) If a child is treated for middle ear infection, why should you wait at least 4 weeks before conducting a rescreen? (Allow time for middle ear fluid to dissipate.) What are the three keys to conducting effective screening? (Good probe fit, minimizing external noise in the environment, minimizing internal noise caused by the child s movement.) 13

Activity 5 10:30 12:00 Conduct Hearing Screenings with Children 1. Assemble participant teams and prepare them for the screening activity. 2. Provide teams with necessary materials (screening forms, probe tips, sanitary wipes, toys, zip-lock bags). Reiterate the purpose of each of the materials. 3. Discuss the logistics of how the screening will be conducted eliciting input from the host site representatives on where each team should set up their screening stations, how children will be brought to the screening stations, and what child identification numbering system should be used on Screening Forms, if any. 4. Instruct teams to complete a screening form on each child who is screened (or on any child who they attempted to screen). 5. Elicit and answer any questions from participants before dispersing to conduct screenings. 6. Inform participants of the time at which the group will reassemble in the training room to debrief the experience and have lunch. 7. Debrief the hearing screening experience with participants after they reassemble. Ask participants what worked well for them, what they found challenging, and to share any observations they have on effective screening strategies. Lunch 12:00 12:45 14

Activity 6 12:45 1:15 Review Equipment Care and Helpful Hints 1. Prepare participants to watch Part 4 of the training video using the following prompt: In this final segment of the video, we ll cover some important elements related to care of your screening equipment and helpful hints that will make screening easier. Points to pay particular attention to include: How to maintain the probe, which is the most fragile part of the equipment. The importance of running regular calibration checks on your equipment (if applicable to the type of screening equipment participants will be using.) The need to have screening equipment recalibrated on a yearly basis. Helpful hints for being an effective screener; ideas for screening the small number of children who are difficult to screen. 2. Show Part 4 of the training video, Getting a Hearing Head Start: Updating Early Childhood Hearing Screening Practices. (Note that the information in the video appears in the Instructional Guide.) Note that the first portion of Part 4 demonstrates a manual calibration check which is needed for some equipment. If the equipment being used in your training does not require regular manual calibration checks, you may fast forward through this portion of Part 4. Stop at the end of Part 4, which is the conclusion of the training video. 3. Review specific equipment care information, provided by the manufacturer, for the equipment used in this particular training. There are a number of equipment-specific issues that could not be addressed adequately in the training video, so use this opportunity to discuss and demonstrate: How to clean and maintain the probe (some probes must be cleaned with a cleaning wire when they become clogged; others have small filters or nozzles that can be changed.) How to run a calibration check on the equipment at least weekly. Note that not all equipment models require weekly manual calibration checks. Check the manual for the equipment being used to see if this is required. If so, demonstrate the process and have the participants follow along running a calibration check on their own equipment. Describe the message they should see if the equipment is functioning properly and the message that may appear if the equipment is not functioning properly. When and how to have the equipment calibrated by the manufacturer. Provide details of the costs associated with recalibration and what programs need to do to receive this maintenance. 15

How to order additional probe tips. Direct participants to the product information that describes how and where additional tips can be purchased. Remind participants NOT to wait until the last minute before screening to order additional tips. Other issues relevant to the specific model of screening equipment being used. 1. Raise and respond to commonly-asked questions about screening, including: Should children who have Pressure Equalization (PE) tubes be screened? OAE hearing screening may and should be performed on children who have PE tubes. Some equipment models need to be adjusted when screening a child with PE tubes. Check the equipment manual for this information. PE tubes are often inserted through the eardrum of children who have chronic middle ear infections or other problems affecting the middle ear system. PE tubes ventilate the middle ear space, allow fluid to drain out, and help to equalize the pressure in front of and behind the eardrum. Children whose PE tubes are functioning properly, and are not occluded, will generally pass the OAE screening indicating that the middle ear is healthy. An OAE screening "refer" result may indicate that a PE tube is not functioning properly and that the child needs to be referred to a health care provider for a middle-ear evaluation, How often should screenings be conducted? Each Head Start program is required to ensure that all children receive a hearing screening within 45 days of enrollment and at least annually. Depending on their capacity, programs may opt to screen more frequently. In any case, all programs should be encouraged to constantly be aware of children s hearing health and to screen an individual child whenever a parent indicates concern over hearing or language development, there is a history of childhood hearing loss in the family, a tendency toward repeated ear infections, or if the child experiences head trauma or an extended illness involving high fever. Programs need to think of the OAE equipment as a valuable tool they can use at their own discretion to screen for hearing health. 5. Encourage participants to enlarge their screening repertoire when they return to their home sites by trying different screening strategies, including: Creating a kit of age-appropriate, visually interesting toys that are kept with the screening equipment. For example, younger children are usually most attracted to simple, colorful toys, or may be attracted to something as simple as a sticky ball of masking tape! Slightly older children will like to watch or play with finger puppets and may also enjoy watching the face of the screening equipment or helping with the screening by pushing the buttons. Screening during naptime. Screening in different environments. Some children will respond best if they are in an environment where they are not being distracted by their peers. Other children enjoy watching the screening process and taking turns having their ears screened. When screening in a home environment, screeners may need to be able to take charge and enlist parents in turning off the TV and radio and/or keeping other children quiet or entertained in another room. Techniques for eliciting cooperation from difficult-to-screen children described in the Instructional Guide. 16

6. Acquaint participants with additional resources included in the Instructional Guide: Information for teachers Sample Letters for parents and physicians Screening log Mini-grant proposal 17

Activity 7 1:15 1:45 Establish a Hearing Screening Data Collection and Tracking Process 1. Provide each Head Start program with Hearing Screening and Diagnostic Follow-up Forms based on the numbers of children, 0 3 years of age, they anticipate screening at their program. Programs will need at least one screening form for each child enrolled, with extras for children who will be rescreened after referral for medical care (approximately 10%). They will also need a similar number of Diagnostic Follow-up Forms for documenting the findings and treatments associated with referrals. 2. Elicit information from each Head Start program about their plans for starting hearing screening. Find out when they will begin and by what date they anticipate submitting their first set of completed Screening Forms to the project. 3. Discuss how the screening and follow-up information will be used in their current data base tracking systems. Encourage programs to add necessary fields in their tracking systems so that all information from the screening forms can be entered. 4. Discuss the importance of prompt follow-up and what mechanisms can be used to ensure that children not passing the OAE screening are referred to health care providers AND that subsequent diagnostic and treatment information is obtained back from health care providers. This is critical so that rescreening can be done in a timely way. It is important to remind participants that all children referred to health care providers as a result of not passing the OAE screening MUST BE RESCREENED after medical clearance. If children still do not pass the OAE screening, they will need to be referred to a pediatric audiologist for a complete evaluation. Talk about how these processes can be tracked and referrals expedited. 18

Activity 8 1:45 2:00 Evaluate the training 1. Discuss how the consulting audiologist and other members of the training team can support subsequent hearing screening and follow-up processes, including: Screening Practices Referral Practices Community Outreach Equipment Concerns Individual Case Consultation Administrative Duties Monitoring for quality (pass/refer rates, adherence with protocol etc.) 2. Elicit final questions and feedback about how effective the training experience was for participants. 3. Have each participant complete the OAE Knowledge Test found on pages 32-33 of the Instructional Guide. Review the answers once completed. 4. Have each participant complete the Training Workshop Evaluation found in the Appendix and on the website. 19